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National Provider Identifier (NPI)
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> National Provider Identifier (NPI)
Who is Eligible to Receive an NPI? Who is Ineligible to Apply for an NPI? How Does a Provider Get an NPI? Where Can I Learn More About NPI?
Latest Update: March 3, 2009
The National Provider Identifier (NPI) is a 10-digit standard unique identifier for health care providers. It replaces any health care provider identifiers in use today, including the nine-digit Medi-Cal provider number. Health Insurance Portability and Accountability Act (HIPAA) of 1996 required a standard unique identifier for all health care providers for use in the nationwide health care system- the NPI. The application process for NPI began on May 23, 2005. The National Plan and Provider Enumeration System (NPPES) was developed by the Centers for Medicare & Medicaid Services (CMS) in compliance with the HIPAA requirement. NPPES is the CMS-sponsored data repository for NPI-related information. It processes new applications, updates and generates NPIs. The NPPES website address is https://nppes.cms.hhs.gov. The NPI Enumerator is a CMS-contracted vendor that will perform provider registration and enumeration processing using the NPPES. The Enumerator enters data from paper applications, resolves problems and answers questions related to NPI and the registration process. Once the data processing is completed, the Enumerator will notify providers of their assigned NPI. The NPI Enumerator’s contact information is as follows: Phone: 1-800-465-3203 or TTY 1-800-692-2326 E-mail: customerservice@npienumerator.com Mailing Address: NPI Enumerator PO Box 6059 Fargo, ND 58108-6059
Who is Eligible to Receive an NPI? An entity who meets the definition of a “health care provider”- any provider of medical or other health services, and any other person or organization that furnishes, bills, or is paid for health care in the normal course of business (45 CFR 160.103). Under HIPAA, a covered health care provider is any provider who transmits health information in electronic form in connection with a transaction for which standards have been adopted. In accordance with the Implementation Guides instructions, the covered health care providers must obtain an NPI and use the number in all HIPAA transactions. The NPI may also be used on paper claims, but HIPAA does not govern that method of submitting claims.
Who is Ineligible to Apply for an NPI? Any entity that does not meet the definition of a “health care provider” (45 CFR 160.103). Examples are non-emergency transportation services, companion services, language interpretation services, billing services and health care clearinghouses. Also included are other providers who are health care providers but are not covered entities because they do not transmit information electronically using the HIPAA standards. However, in some cases, they are encouraged to apply for an NPI since it may be required for billing purposes by another provider to whom a referral has been made. If a non-covered health care provider obtains an NPI, it does not make the provider a covered entity. How Does a Provider Get an NPI? There are three options: (1) Web Application, (2) EFI Bulk Enumeration, or (3) Paper Application. Web Application
EFI Bulk Enumeration
Paper Application
Providers are encouraged to include their Medicare identifiers and those issued by any other health plans. Also, include the associated State name when reporting a Medicaid identification number. The legacy identifier information is critical for health plans in the development of crosswalks to aid in the transition to the NPI. Once the NPI application has been submitted and an NPI has been assigned, NPPES (or EFIO, if the healthcare provider was enumerated by way of an EFIO) will send a notification that includes their NPI. The notification is proof of NPI enumeration and provides the information that will enable trading partners to verify the health care provider’s NPI. Where Can I Learn More About NPI? The CMS website is the best source for more information: http://www.cms.hhs.gov/NationalProvIdentStand/ For Frequently Asked Questions, scroll down the first page of the CMS website. For further assistance, please contact Leyla Avila at lavila@cpca.org or at (916) 440-8170 x 245.
Copyright ©2005 California Primary Care Association. Contact information and legal disclaimers.
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